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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625191
Report Date: 09/03/2024
Date Signed: 09/03/2024 10:30:04 AM

Document Has Been Signed on 09/03/2024 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DYACHISHIN, ANNETTEFACILITY NUMBER:
343625191
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
09/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Svitlana HayduchykTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 9/3/2024 at approximately 08:40AM, Licensing Program Analyst (LPA) Michelle Perez met with assistant Svitlana Hayduchyk. Licensee was not present for the inspection and stated that she was at an appointment. LPA informed licensee on the telephone, during the inspection, that per regulations, licensee is to be present for 80% of their operating hours, per day. Operating hours are Monday through Friday, 8AM to 5PM, per licensee, as no changes have been made and submitted to licensing. During the inspection there was a census of 4 CHILDREN supervised by the assistant. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: Rear yard, bedroom #3 and bathroom, Bedroom #2, bathroom #3, kitchen and living area, garage, office & master room. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. There are no bodies of the water on the premises.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191
VISIT DATE: 09/03/2024
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LPA observed a children's roster and fire drill log, the last fire drill was conducted April 2024. Licensee's has current CPR/First aid, which expires July 2025. Assistants CPR expires May 2026. Licensee’s Mandated Reporter Training expires August 2025. Assistant does not have mandated reporter, due to language barrier. Licensee understands both training’s must be completed every two years. LPAs reviewed records of children’s files, all which contained the required documentation. LPA reviewed the assistant file, and noted the LIC 9108 was missing and LIC 9052, employee rights.. Technical assistance was provided.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191
VISIT DATE: 09/03/2024
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Licensee is practicing safe sleep regulations.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
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Document Has Been Signed on 09/03/2024 10:30 AM - It Cannot Be Edited


Created By: Michelle Perez On 09/03/2024 at 10:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DYACHISHIN, ANNETTE
FACILITY NUMBER: 343625191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
This was not evidenced by: LPA arriving for inspection and licensee was not present for entire inspection and stated would not return for several hours.
POC Due Date: 09/24/2024
Plan of Correction
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LPA will return at a later date to clear the citation, and verify that the licensee is present.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Keven Peters
LICENSING EVALUATOR NAME:Michelle Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


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